Do the Right Thing but Do No Harm: No Really, It’s Not Always Easy

It’s 11 pm and I’m running the ED patient list with my resident. She has a lot of questions.

The patient in room 3 seems like he has a classic appendicitis but the ultrasound is “unable to visualize” the appendix. Should he now get a CT scan or should I insist the surgeons consider operating without it?

In room 11, this young child’s forearm fracture is not too displaced and the textbooks say that it will likely heal well as is. But should we sedate her anyway to get it in perfect alignment and place it in a cast?

And that patient in room 8 watching The Incredibles has a matching high potassium level of 8.0. It is hemolyzed (of course) so it’s probably a false positive but should we get another one?

Maybe it’s me but each question seems to end with the phrase, “Just to make sure…” Is it as innocent as that or is there another way to think about these borderline tests and procedures?

Atul Gawande, a general surgeon and author, recently wrote in the New Yorker that unnecessary care and over-testing are not helping patients and in some cases harming them.1 He describes a study of 26 tests that were defined as unnecessary because they have been repeatedly shown to make no difference in health outcomes (for example an EEG for a straightforward headache). Despite their lack of utility, the study found a significant proportion of Medicare beneficiaries received at least one of 26 tests. In addition to not changing patient outcomes, these “low-value” tests can add worry, false hope, and cost. In some cases—he tries to talk a woman out of a questionable surgery that results in complications—inappropriate care can be outright harmful.

In pediatric emergency medicine, we are acutely aware of over-testing and inappropriate care since the implications of lab draws, radiation, and interventions are often magnified in children. In many instances we should do less, not more. From fewer head CTs and infant LPs to smart airway management to avoid intubation in seizures, a significant part of the pediatric emergency medicine skill set is recognizing when interventions are indicated and when we should get out of the way and let kids heal on their own.

But pediatric emergency medicine is not immune from low-value testing and care. Viral testing in healthy school-aged children with viral symptoms, blood cultures in highly febrile but otherwise healthy children, and almost everything for bronchiolitis2 are low value when performed routinely. Rapid MRIs are a no-radiation imaging alternative to CT scans that are more feasible in the ED than traditional MRIs. These features also make rapid MRI a candidate for excessive and inappropriate use as it becomes more widely available. Despite my best intentions, I admit to participating all of these low-value activities at one time or another.

What drives this unnecessary care? Gawande cites financial incentives, hard to break habits, and lack of knowledge. In my own practice, inappropriate care can be even more complicated. On busy nights, when patients and families fill the waiting room and hallways, I might order a test to buy time to think (and “just to make sure,” I probably tell myself) and see to the next patient. Some days I am probably subconsciously more risk averse—or maybe it’s “lawsuit averse”—whether it’s because a case study I just read, a personal medical experience, or a recent patient who returned for care. One way of transferring risk from myself is to do more testing, interventions, and consultation. The opaque costs of tests and interventions in the ED and the uncertainty of follow-up also likely influences my decision to test or treat.

And then there are the expectations of patients and families themselves. Maureen Dowd, a New York Times columnist, recently wrote an op-ed about a young woman who was diagnosed with a stroke in the ED.3 She quotes a Harvard neurologist who disparagingly says that he is “afraid of the emergency room” because he thinks it’s dangerous and that “If you have problems with the brain, ask for a neurologist.” Dowd does not question this statement, taking it at face value that ED evaluations are inadequate and specialty care should always be the standard.

Inappropriate demand for specialty care can lead to more testing, sub-specialists, and sub-specialists’ testing. Similarly, sometimes patients are referred emergently to a pediatric ER because they are told that more specific testing needs to be done—often “just to make sure”—when in reality no more is required.

All of these factors can make over-testing easy and doing the right thing hard. I wring my hands and lose more sleep because of the test I didn’t order than the all of the ones I did. It’s still early but tonight promises to be a long and sleepless one.

Assistant Clinical Professor at University of California at San Francisco

Sonny's academic interests are in team performance in resuscitation, developing learning platforms for medical education, and transitioning academics to the digital age. Sonny created PEMAcademy, a collaborative regional blog for PEM education and is the Editor-In-Chief of the PEMNetwork Blog. His hobbies include photography and cooking.

Sonny Tat

Sonny's academic interests are in team performance in resuscitation, developing learning platforms for medical education, and transitioning academics to the digital age. Sonny created PEMAcademy, a collaborative regional blog for PEM education and is the Editor-In-Chief of the PEMNetwork Blog. His hobbies include photography and cooking.